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Health Plan Accreditation

NCQA’s Health Plan Accreditation is based on a group of comprehensive requirements that measure plan performance.

Until 1990 there was no comprehensive way to evaluate a health plan’s quality, no standards of quality to evaluate plans against.

NCQA developed the first set of standards for health plan quality. Its Health Plan Accreditation program is based on a set of evidenced-based requirements that measure plan performance and provide employers with a way to evaluate current and prospective plans.

Although NCQA now evaluates, certifies, recognizes and accredits a variety of health care organizations and providers, its Health Plan Accreditation program is the gold standard for evaluation programs across the industry.

What Is Health Plan Accreditation?

NCQA’s Health Plan Accreditation program builds on almost three decades of experience measuring the quality of health plans. An organization that earns Accreditation meets standards covering more than 100 measured elements.

The standards focus on:

  • Quality Management and Improvement
  • Population Health Management
  • Network Management
  • Utilization Management
  • Credentialing
  • Member Experience

Key features of Health Plan Accreditation include:

  • Focusing not only on how health plans comply with medical standards but, also behavioral healthcare standards.
  • Extensively evaluating plans’ population health management efforts, including how they identify member needs and enroll members in appropriate programs.
  • Mandating that health plans comply with rigorous utilization management standards, so members are receiving treatment decisions that are timely and evidence-based.
  • Measuring the availability and accessibility of primary care physicians, specialists and behavioral health care practitioners.

What Does Health Plan Accreditation Mean for Employers?

The rigor of the requirements, combined with onsite review of patient files, means that earning NCQA Accreditation is more than a “check the box” process.

For employers—whether they are self-insured or fully insured—NCQA Accreditation means that an independent, nationally recognized organization has validated a plan’s performance.

Without NCQA Accreditation, there is no assurance for employers that a health plan is truly committed to meeting quality standards.

What Should Employers Do?

Employers should ask their current or prospective health plans if they are NCQA Accredited.

They can also find information about Accredited plans on NCQA’s Report Cards—for example, how a plan scored in categories such as keeping members healthy and helping them get better.

Employers should include requirements in their RFP that health plans are Accredited through NCQA.

 

Have a question? NCQA’s Employer Relations Team can help!

Contact the Employer Relations Team

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